Successful collaborative model for STEMI care between a STEMI-referral and a STEMI receiving center.

BACKGROUND: Patients with ST-segment elevation myocardial infarction (STEMI) greatly benefit from a rapid door-to-balloon (D2B) time. For hospitals without a catheterization laboratory, it is imperative to establish partnerships with a STEMI receiving center (SRC). STEMI systems of care have been established to facilitate these relationships to improve rapid reperfusion. We describe the experience and benefits of such a relationship. METHODS: A partnership between our 2 institutions was established in April 2011. Saint Anthony Hospital (SAH) of Chicago is an inner city hospital with interventional cardiologists on staff, but no catheterization laboratory. Before the partnership, STEMI patients were transferred 8 miles to a percutaneous coronary intervention (PCI) hospital on the city's north side. Rush University Medical Center (RUMC) is an academic medical center with 24/7/365 PCI capability. SAH decided that a transfer relationship with a closer SRC would benefit patient care. The following steps were taken: both hospitals signed a STEMI transfer agreement for STEMI transfers regardless of insurance status; an education process occurred at both hospitals; agreement that transferred patients would follow-up at the STEMI referring hospital (SAH); a contract with a single ambulance provider was signed; a simple STEMI protocol was adopted. RESULTS: In 2010, SAH saw 20 patients with STEMI. Average time from patient arrival to leaving the emergency department (ED) [Door-in-Door-out (DIDO)] was 83 minutes, these times were not tracked carefully; approximate transfer time to SRC was 25 minutes; Door1-2-Balloon (D12B) time was not recorded. Since the new protocol, 44 patients transferred to RUMC for PCI to date. Median (inclusive minimum, maximum) time from ED arrival (D1) at referral hospital to SRC (D2) was 52 minutes (56, 192) for all PCI cases; 11 patients transferred did not have PCI; 1 patient expired upon arrival; and median time to first PCI device (D12B) was 86 minutes (53-167). DISCUSSION: Streamlining STEMI patient care to reduce D2B is a major priority. We have demonstrated that establishing a transfer program between a STEMI-Referral Hospital (SRH) and SRC can markedly improve time to reperfusion. This approach has resulted in D12B that match or exceeds the D2B for nontransfer patients at most STEMI-receiving hospitals.

Achieving high quality in ST-segment elevation myocardial infarction care: one urban academic medical center experience.

Management of acute myocardial infarction with ST elevation (STEMI) remains a challenge for academic institutions. There are numerous factors at play from the time electrocardiogram is obtained to the time the patient arrives to a catheterization laboratory and the balloon is inflated. Academic hospitals that are located in large urban centers have to deal with staff living long distances from the facility, and therefore, assembling the catheterization team after-hours and on the weekends becomes a difficult task to achieve. There are other factors that contribute to time delays, such as, administering electrocardiograms in timely fashion, having emergency physicians activate the catheterization team, instead of contacting the cardiologist to discuss the case, and other time-sensitive factors. All of the aforementioned issues contribute to the delay. Yet, primary percutaneous coronary intervention is clearly demonstrated as the modality of choice in treatment of STEMI, which improves patient's morbidity and mortality. Therefore, it is imperative that institutions do all they can to improve their protocols and meet the core measures in the treatment of STEMI patients, including the door-to-balloon time of less than 90 minutes. Our institution started a quality improvement program for STEMI care in 1993 and has showed progressive improvement in use of aspirin, beta-blockers, angiotensin-converting enzyme inhibitors, and other medication, culminating in 95% to 100% use of these medications in 2003-2004, when we operated in accordance with the Get With The Guidelines program. Door-to-balloon time in less than 90 minutes became a new phase in our quality improvement process, and we achieved 100% compliance in the last 2 years.

A written policy increases compliance with guidelines for therapeutic anticoagulation prior to elective direct current cardioversion of atrial fibrillation.

BACKGROUND: Therapeutic anticoagulation before elective direct current cardioversion (DCC) of atrial fibrillation reduces the risk of embolic stroke. Direct current cardioversion is performed by a variety of practitioners, and variable adherence to preprocedural anticoagulation guidelines is common. OBJECTIVE: We assessed the impact of a written policy on guideline compliance. METHODS: : Anticoagulation status and transesophageal echocardiogram (TEE) results were reviewed in 55 patients (32 men/23 women; ages 18-83 years) who underwent elective DCC during the 6-month period before a written anticoagulation policy was sent to physicians who perform, prepare, or refer patients for this procedure. The nurse assigned to each DCC was responsible for documenting anticoagulation status. In accordance with guidelines, therapeutic anticoagulation was defined as a normalized ratio range > or = 2.0 for at least 3 weeks or a negative TEE with a normalized ratio range > or = 2.0 or a partial thromboplastin time > 50 seconds at the time of DCC. Immediately after policy implementation, anticoagulation status and TEE results were reviewed in 53 patients (42 men/11 women; ages 21-84 years) and 1 year post-policy implementation. RESULTS: Before policy implementation, 14 of 52 patients (27%) had DCC performed without adequate anticoagulation or a negative TEE. Immediately postimplementation, only 2 of 50 patients (4%) had DCC performed without adequate anticoagulation or a negative TEE (P = .002). One year post-policy implementation, only 4 of 48 patients (8%) had DCC performed without adequate anticoagulation or a negative TEE (P = .03). CONCLUSIONS: Implementing a written policy greatly reduces the number of patients undergoing DCC without adequate anticoagulation or a negative TEE. The impact of this intervention was quickly demonstrable and persisted during follow-up. Supplementing published recommendations with guideline-driven policies may reduce variations in clinical practice and improve quality of care.